Natoshia R. Cunningham

Objective: Chronic pain in youth is common, affecting over 20% worldwide. While effective nonpharmacologic interventions are available, including psychological therapies and physical interventions, it is critical to ensure available interventions are culturally relevant. The objective of this scoping review is to understand nonpharmacologic interventional strategies used for youth with chronic pain conditions in Mediterranean countries and rate the quality of the evidence. Methods: Search terms to identify nonpharmacologic treatments for youth with chronic pain in Mediterranean countries (e.g., Spain, Portugal, France, and Italy) were run in six databases on March 11, 2025, including Medline (PubMed), Embase (Elsevier), SciELO (Web of Science), and PsycInfo (ProQuest). Covidence software was used to screen abstracts and then full texts by two independent reviewers. Results: Of the 6,158 abstracts screened, 35 articles were identified for inclusion in the review. They included (1) psychological/educational interventions (n = 18), (2) physical interventions (n = 9), including pain neuroscience with targeted muscular exercises, (3) dietary interventions (n = 7), including a low FODMAP diet and dietary supplements, and 4) a mixed (cognitive behavioral therapy, diet, and exercise) intervention. Conclusions: A comprehensive skill-based approach, including psychological strategies (e.g., cognitive behavioral and mindfulness meditation) and healthy lifestyle recommendations (e.g., dietary modification and sleep hygiene), may be a culturally relevant approach to care of Mediterranean youth with chronic pain.

Objective: Our objective was to determine the feasibility and acceptability of the Treatment and Education Approach for Childhood‐Onset Lupus (TEACH), a six‐session cognitive behavioral intervention addressing depressive, fatigue, and pain symptoms, delivered remotely to individual youth with lupus by a trained interventionist. We expected that TEACH would be considered feasible and acceptable based on recruitment and retention rates. We also examined the effect of TEACH on youths’ depressive, fatigue, and pain symptoms compared to medical treatment as usual (TAU). Methods: A pilot two‐arm longitudinal randomized controlled clinical trial was conducted. Adolescents (12–17 years) and young adults (18–22 years) with childhood‐onset systemic lupus erythematosus and elevated depressive, fatigue, and/or pain symptoms were recruited from six pediatric rheumatology sites across the United States and Canada from August 2020 to March 2023. Participants were randomized 1:1 to TEACH and TAU or TAU alone and reported symptom data at baseline and eight weeks later. Results: Of the 200 youth approached, 97 consented to participate (48.5% recruitment). Among 64 eligible participants, 32 were randomized to TEACH and TAU and 32 to TAU alone. Retention was high (92.2%). At postassessment, the intervention group demonstrated reductions in depressive (C _emm 7.88, 95% confidence interval 3.20–12.60; 14%) and fatigue (C _emm 3.91, 95% confidence interval 0.44–7.39; 7%) symptoms but not pain (C _emm 0.89, 95% confidence interval −0.06 to 1.84). Conclusion: This remotely delivered cognitive behavioral intervention tailored to youth with lupus was feasible and associated with reduced depressive and fatigue symptoms compared with medical TAU. Further increasing accessibility by implementing TEACH in medical settings may improve uptake and patient outcomes. image

Background/Objectives: Physical and mental health symptoms commonly affecting children are often under-addressed given the limited availability of pediatric behavioral healthcare. Training school providers (e.g., nurses, mental health professionals) to address these concerns is a promising strategy to explore, considering the unique level of accessibility afforded by school settings. While our earlier work augmented school providers’ pain management skills, providers desired more comprehensive training and youth support tools. Our team of interdisciplinary academic researchers and community partners will bridge this gap by developing the PURSUIT (Preventing Use of Substances for the Underserved with Innovative Technology) provider training program and companion online self-management platform for youth and caregivers. This protocol paper describes our planned approach to developing, implementing, and evaluating the PURSUIT program. Methods: We will draw from evidence-based cognitive–behavioral, trauma-focused, and mindfulness protocols to develop a comprehensive provider training program and interactive online self-management platform for youth and caregivers. Content areas will include core cognitive–behavioral strategies and specific skills for pediatric pain management, trauma-focused care, and substance use prevention. Innovative technological approaches, such as live and animated videos, will be used to promote user engagement. Academic and community partners will have roles in material co-development. Outcomes of this project will include the PURSUIT training program and self-management platform feasibility and acceptability (e.g., completion/engagement rates, quantitative/qualitative reports), as well as the impact of the training program on provider knowledge and the impact of the self-management platform on youth/caregiver outcomes. Conclusions: Interdisciplinary collaboration and community engagement will be critical to developing and evaluating a provider training program and youth/caregiver self-management platform.

Objective: Up to 60% of youth with childhood‐onset systemic lupus erythematosus (cSLE) experience cognitive dysfunction, impacting their quality of life and medication adherence. This study explored self‐reported executive function (EF) and its links to patient‐reported outcomes and disease‐related factors in cSLE. Methods: This cross‐sectional study compared patients aged 10 to 17 years with cSLE to age‐ and sex‐matched controls. The Behavior Rating Inventory of Executive Function Self‐Report Global Executive Composite (GEC) T score measured daily EF activities, whereas Patient‐Reported Outcomes Measurement Information System (PROMIS) questionnaires assessed pain, sleep, fatigue, anxiety, and depression. Group differences in GEC and correlations with PROMIS scores were analyzed. For patients with cSLE, hierarchical regression evaluated GEC variance explained by income, PROMIS scores, and disease‐related factors (activity, damage, and glucocorticoid use). Results: We recruited 94 participants, including 52 patients with cSLE and 42 controls. The analysis revealed no group difference in GEC T scores. In the cSLE group, worse depression and sleep disturbance correlated with worse GEC T scores, whereas pain interference and fatigue correlated with GEC in both groups. The hierarchical regression model explained 30% ( P = 0.003) of EF variability in cSLE. PROMIS measures accounted for 14% ( P = 0.013) of EF variability when controlling for household income. Disease‐related factors contributed an additional 14% of EF variability, with higher disease activity and lower glucocorticoid use associated with worse GEC T scores. Conclusion: Self‐reported EF was similar in patients with cSLE and control patients but correlated uniquely with depression, sleep disturbance, disease activity, and glucocorticoid use. Further research is needed to improve EF in cSLE.

Integrated behavioral healthcare has addressed common pediatric primary care concerns including anxiety and depression, but is infrequently applied to somatic symptoms (e.g., chronic pain, fatigue, or syncope unattributable to organic causes), which affect one in three youth. Developing an integrated care model for primary care–where most youth with somatic symptoms first present for evaluation and management–may increase access and positively impact child health. This manuscript summarizes the literature surrounding integrated care for pediatric somatic symptoms and proposes an adapted model for primary care. Drawing from the Pediatric Psychosocial Preventative Health model and cognitive-behavioral protocols for somatic symptom management, we propose that youth with mild to moderate symptoms can be effectively co-managed in primary care by a primary care provider delivering psychoeducation and facilitating team coordination, and an embedded behavioral healthcare provider conducting a brief, targeted intervention. This innovative approach leverages shared clinical responsibilities, as well as youth and families’ trust in the primary care setting, to accessibly deliver care for mild-moderate symptoms otherwise unaddressed in current management approaches. Implementation likely requires developing clinician support tools and identifying sustainable billing practices, but may result in accessible, holistic, care that curtails symptom persistence and/or progression.

Background: The Aim to Decrease Anxiety and Pain Treatment (ADAPT) is a blended, digital, and live cognitive behavioral therapy program for children with functional abdominal pain disorder (FAPDs) and anxiety. Initially developed and evaluated in US pediatric gastroenterology settings, a culturally refined version was developed in Swedish, for potential use within community-based pediatric health care settings. Objective: This study aimed to evaluate a modified version of ADAPT as an early intervention for FAPD within a community-based pediatric setting in Sweden, exploring both the potential treatment effect and participants’ treatment experience. Methods: Participants were aged 9‐14 years, and all were diagnosed with FAPD. Using a mixed methods design, the study examined the preliminary effect through a single-arm pre-posttest and treatment experience through semistructured child interviews. Data were analyzed in three steps: nonparametric quantitative analysis of results on pre- and postintervention measures of self-rated pain-related functional disability, pain intensity, and anxiety; thematic qualitative analysis of the interviews; and conversion of qualitative data to enable both datasets to be analyzed and presented together. Results: A total of 13 children (12 girls) participated in ADAPT, all completing the program. In total, 7 of the invited 13 participating children agreed to be interviewed following intervention completion. Quantitative results were analyzed using the Wilcoxon signed rank test, and Pearson r was used to calculate the effect size. Results showed a significant reduction in pain-related functional disability, with a median decrease from 14.00 (IQR 10‐20) preintervention, to 5.00 (IQR 1‐9) postintervention (P=.04), a large effect size, r=−0.58, and 46% (n=6) achieving a clinically meaningful change where a Functional Disability Inventory (FDI) score decrease of ≥7.8 points denoted a clinically meaningful treatment response. Pain intensity also significantly decreased from a median of 6.5 (IQR 5.25‐8) to 4.00 (IQR 2.5‐6.5; P=.02), a large effect size r=−0.70, with 33% (n=4) experiencing at least a 50% reduction. Clinically meaningful change was determined to be present if at least a 50% reduction in self-rated measures of pain intensity was observed. Qualitative thematic analysis identified three themes: “Starting from scratch,” “Experiencing the treatment,” and “Getting on with life.” In terms of treatment experience, the blended live or digital format was perceived as a good fit for youth. Most children described finding some strategy that was effective and reported positive outcomes, such as increased participation in school. Conclusions: As patient experiences were predominantly positive and quantitative results indicative of potential for increased function and reduced pain, our findings suggest that ADAPT may present as a possible early treatment option for FAPD in a Swedish community–based pediatric setting. To draw robust conclusions on effectiveness, further research is required using a larger sample size, as well as research aimed at following up treatment effects over time.

Objective: Pediatric rheumatologic diseases (PRDs) are characterized by high rates of anxiety and depression known to impact health‐related outcomes. We present guidance statements to assess and manage mental health concerns for youth with PRDs in pediatric rheumatology practice.Methods: Development of the guidance statements was initiated in 2019 and concluded in November 2023. It included (1) the formation of a task force (including pediatric rheumatologists, pediatric behavioral health providers, patients, and parents) led by two licensed pediatric psychologists and two board‐certified pediatric rheumatologists, (2) iterative drafting of statements and rating of evidence based on the Oxford Centre for Evidence‐Based Medicine levels of evidence, (3) an open comment period followed by revision of statements, (4) a Delphi panel process to attain consensus on the statements, and (5) review by the American College of Rheumatology (ACR) Committee on Quality of Care and refinement of statements to an identified list of those with the strongest empiric evidence for endorsement by the ACR.Results: The task force drafted 34 statements for addressing mental health concerns in pediatric rheumatology, including identification, management, and clinic environment/education considerations. After two rounds of Delphi panel voting by a random sample of 76 members of the Childhood Arthritis and Rheumatology Research Alliance, 31 statements attained at least 80% consensus. Eleven of those statements had high empirical support and endorsement and were thus selected as the final guidance statements, including recommendations for depression and anxiety screening in youth aged 12 years and older, management of identified symptoms, and education of patients about mental health.Conclusion: It is a goal that these recommendations be used to empower pediatric rheumatology teams to consider how they may better address mental health concerns in their setting and help improve both mental health– and health‐related outcomes for youth with rheumatologic diseases. image

Objectives: Anxiety disorders affect 20%–50% of youth with chronic medical conditions (CMCs) and can interfere with medical care and treatment outcomes. Psychological therapies are typically designed for youth without CMCs; thus, this systematic review (Open Science Framework preregistration osf.io/a52nd/) assesses the effect of psychological therapies on anxiety, functional impairment and health-related quality of life (HRQOL) in this unique population. Methods: We included randomized controlled trials of psychological therapies vs. any comparator for youth (ages 24 and younger) with CMCs that assessed child anxiety. We excluded studies of adults and those not in English. Medline, Embase, PsycInfo, and CENTRAL databases were searched, studies were screened using COVIDENCE software, and meta-analysis was undertaken in R. Study quality was assessed using the Cochrane Risk of Bias tool, version 2. Quality of evidence was assessed using the GRADE system. Results: Thirty-three studies with 2676 participants (ages 5–21 years) were included in the meta-analysis. Nearly all had at least some risk of bias. Overall, psychological interventions resulted in lower anxiety (Hedges’ g = −0.48 [−0.71; −0.25]), but did not have a significant effect on functional impairment or HRQOL. Based on the GRADE criteria, we have moderate confidence in these results. Treatments with higher risk of bias and those with live therapist components had greater effects on anxiety. Conclusions: Psychological interventions may be effective for improving anxiety for children and youth with CMCs, particularly those with a live therapist. More high-quality studies are needed to understand what components produce the best outcomes for patients.